BMJ  2004;329:239 (24 July), doi:10.1136/bmj.329.7459.239-a

reviews

SOUNDINGS

Unsung heroes

I often feel besieged by all the guidance documents from various committees. The difficulty is both the volume and the fact that they rarely tell you not to do something. I should apparently be urgently referring everyone with a sore throat of more than six weeks' duration and anyone with any dysphagia (even a teenager with tonsillitis?).

A recent editorial in this journal referred to general practice as the "risk sink" of a publicly funded health service ( BMJ 2003;326: 234-5[Free Full Text]). Every day hundreds of thousands of investigations are not done because generalists, or specialists, accept that the risk-benefit balance doesn't warrant it. These people are the unsung heroes that maintain the viability of the NHS.

In the 1980s the guidance was for general practitioners never to initiate angiotensin converting enzyme (ACE) inhibitors in patients with heart failure. It had to be done in hospital. Even a few years ago the guidance defining those patients who must be admitted into hospital to have ACE inhibitors initiated included most patients I would ever see with heart failure. It was necessary to ignore the unrealistic guidance, with the associated medico-legal risk, or else burden unnecessarily an already collapsing hospital system.

It is quite rare to come across guidance that states explicitly that there must be some threshold of risk at which the investigation should not be done. But there must be such a threshold and, as it is a threshold, there will necessarily be some diagnoses that will be missed. The corollary of this, I suppose, is that if a clinician never misses a diagnosis then they are either not seeing enough patients (an old adage), or they are over-investigating those they do see.

The real problem is that the downsides of over-investigation—the patient anxiety generated and the resources clogged up—are hidden. It is the one missed case of colorectal cancer, even though its finding may have been incidental to the presenting symptom, that leads to charges of incompetence. But whoever hears criticism of the doctor who refers everything?

We need realistic guidelines. We try to capture as many early diagnoses as possible. But it is necessary to recognise that, unless we medicalise the whole of society, there will be occasions when, as the Americans say, shit happens. And it is not necessarily our fault.

---

Painswick, Gloucestershire

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Rapid Responses:

Read all Rapid Responses

Shit happens - often

Mark Struthers
bmj.com, 1 Aug 2004 [Full text]

Shit does happen

Oliver J Monfredi
bmj.com, 2 Aug 2004 [Full text]